Healthcare Provider Details

I. General information

NPI: 1679579155
Provider Name (Legal Business Name): DAVID R. EDELSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE STE 501
CHICAGO IL
60602-3833
US

IV. Provider business mailing address

30 N MICHIGAN AVE STE 501
CHICAGO IL
60602-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-332-3699
  • Fax: 312-332-3698
Mailing address:
  • Phone: 312-332-3699
  • Fax: 312-332-3698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: